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| :''See [[Endometrium]] for dating and benign pathologies.'' | | :''See [[Endometrium]] for an introduction to the topic.'' |
| '''Endometrial hyperplasia''', abbreviated '''EH''', is a precursor to [[endometrial carcinoma]]. | | '''Endometrial hyperplasia''', abbreviated '''EH''', is a precursor to [[endometrial carcinoma]]. |
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| =Overview= | | =Overview= |
| The most widely used system is from the World Health Organization (WHO). | | ===WHO endometrial hyperplasia classification of 2014=== |
| | The 2014 WHO system has two categories:<ref name=pmid25797956 >{{Cite journal | last1 = Emons | first1 = G. | last2 = Beckmann | first2 = MW. | last3 = Schmidt | first3 = D. | last4 = Mallmann | first4 = P. | title = New WHO Classification of Endometrial Hyperplasias. | journal = Geburtshilfe Frauenheilkd | volume = 75 | issue = 2 | pages = 135-136 | month = Feb | year = 2015 | doi = 10.1055/s-0034-1396256 | PMID = 25797956 }}</ref> |
| | *Hyperplasia without atypia. |
| | *Atypical hyperplasia/endometrioid intraepithelial neoplasia. |
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| ===WHO classification - overview=== | | ===WHO endometrial hyperplasia classification of 1994=== |
| The WHO system is based on determining: | | The 1994 WHO system is based on determining:<ref name=pmid25797956>{{Cite journal | last1 = Emons | first1 = G. | last2 = Beckmann | first2 = MW. | last3 = Schmidt | first3 = D. | last4 = Mallmann | first4 = P. | title = New WHO Classification of Endometrial Hyperplasias. | journal = Geburtshilfe Frauenheilkd | volume = 75 | issue = 2 | pages = 135-136 | month = Feb | year = 2015 | doi = 10.1055/s-0034-1396256 | PMID = 25797956 }}</ref> |
| # Gland density (normal = ''simple hyperplasia'', high density = ''complex hyperplasia''). | | # Gland density (normal/low = ''simple hyperplasia'', high density = ''complex hyperplasia''). |
| # Presence/absence of nuclear atypia. | | # Presence/absence of nuclear atypia. |
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| | It consists of four categories: |
| | *[[Simple endometrial hyperplasia]]. |
| | *[[Simple endometrial hyperplasia with atypia]]. |
| | *[[Complex endometrial hyperplasia]]. |
| | *[[Complex endometrial hyperplasia with atypia]]. |
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| ===Alternate classifications - overview=== | | ===Alternate classifications - overview=== |
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| #Endometrial intraepithelial neoplasia (EIN). | | #Endometrial intraepithelial neoplasia (EIN). |
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| ==WHO classification== | | ==WHO classification of 1994== |
| ===Management of endometrial hyperplasia=== | | ===Management of endometrial hyperplasia=== |
| *Endometrial hyperplasia with atypia is usually treated with hysterectomy.<ref>URL: [http://www.aafp.org/afp/990600ap/3069.html http://www.aafp.org/afp/990600ap/3069.html].</ref> | | *Endometrial hyperplasia with atypia is usually treated with hysterectomy.<ref>URL: [http://www.aafp.org/afp/990600ap/3069.html http://www.aafp.org/afp/990600ap/3069.html].</ref> |
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| **Progestins + close follow-up ''OR'' hysterectomy. | | **Progestins + close follow-up ''OR'' hysterectomy. |
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| ===Risk of progression to carcinoma=== | | ===Risk of progression to carcinoma as per 1994 system=== |
| Approximate risk of progression to [[endometrial carcinoma]] - Latta rule of 3s:<ref>Latta, E. January 2009.</ref> | | Approximate risk of progression to [[endometrial carcinoma]] - Latta rule of 3s:<ref>Latta, E. January 2009.</ref> |
| {| class="wikitable" | | {| class="wikitable" |
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| |} | | |} |
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| =WHO system= | | ==WHO system of 1994 - detail articles== |
| Almost all hyperplasia is seen in the context of proliferative-type endometrium. [[Endometrial hyperplasia with secretory changes|Hyperplasia in the secretory-type endometrium]] is extremely rare and something diagnosed by or in consultation with an expert in gynecologic pathology. | | Almost all hyperplasia is seen in the context of proliferative-type endometrium. [[Endometrial hyperplasia with secretory changes|Hyperplasia in the secretory-type endometrium]] is extremely rare and something diagnosed by or in consultation with an expert in gynecologic pathology. |
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| ==Simple endometrial hyperplasia== | | ===Simple endometrial hyperplasia=== |
| *[[AKA]] ''simple hyperplasia''. | | *[[AKA]] ''simple hyperplasia''. |
| ===General===
| | {{Main|Simple endometrial hyperplasia}} |
| *More common than simple endometrial hyperplasia with atypia.
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| *Very low risk for progressing to [[endometrioid endometrial carcinoma]].
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| ===Microscopic===
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| Features:<ref name=Ref_GP236>{{Ref GP|236}}</ref>
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| *Irregular dilated glands (with large lumens) - '''key feature'''.
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| **Glands described as "animal shapes".
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| *Variation of gland size.
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| *No nuclear atypia.
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| **Uniform columnar nuclei.
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| *Normal gland density (gland area in plane of section/total area ~= 1/3).
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| DDx:
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| *[[Disordered proliferative phase]].
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| *[[Complex endometrial hyperplasia]] - has increased gland-to-stroma ratio.
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| *[[Atrophic endometrium|Cystic atrophy of the endometrium]] - does not have proliferative activity.<ref name=pmid16873562>{{Cite journal | last1 = McCluggage | first1 = WG. | title = My approach to the interpretation of endometrial biopsies and curettings. | journal = J Clin Pathol | volume = 59 | issue = 8 | pages = 801-12 | month = Aug | year = 2006 | doi = 10.1136/jcp.2005.029702 | PMID = 16873562 | PMC = 1860448 }}</ref>
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| *[[Benign endometrial polyp]] - has thick-walled blood vessels; simple endometrial hyperplasia should not be diagnosed in a polyp.<ref name=pmid16873562/>
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| Images:
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| *[http://commons.wikimedia.org/wiki/File:Simple_endometrial_hyperplasia_-_low_mag.jpg Simple endometrial hyperplasia - low mag. (WC)].
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| *[http://commons.wikimedia.org/wiki/File:Simple_endometrial_hyperplasia_-_high_mag.jpg Simple endometrial hyperplasia - high mag. (WC)].
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| ==Simple endometrial hyperplasia with atypia==
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| ===General===
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| *Very uncommon.
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| ===Microscopic===
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| Features:<ref name=Ref_GP236>{{Ref GP|236}}</ref>
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| *Irregular dilated glands (with large lumens) - '''important feature'''.
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| **Glands described as "animal shapes".
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| *Variation of gland size.
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| *No nuclear atypia.
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| **Uniform columnar nuclei.
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| *Normal gland density (gland area in plane of section/total area ~= 1/3).
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| *Nuclear atypia:<ref>{{Cite journal | last1 = Silverberg | first1 = SG. | title = Problems in the differential diagnosis of endometrial hyperplasia and carcinoma. | journal = Mod Pathol | volume = 13 | issue = 3 | pages = 309-27 | month = Mar | year = 2000 | doi = 10.1038/modpathol.3880053 | PMID = 10757341 }}</ref>
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| **Loss of basal nuclear stratification.
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| **Nuclear size variation.
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| **Nuclear rounding.
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| ***Nuclei lacking atypical = uniform columnar nuclei.
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| **Nucleoli.
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| **Hyperchromasia or vesicular nuclei.
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| Notes:
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| *There are no clear criteria for atypia. Different sources list different features.
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| *VL criteria for atypia (all should be present):
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| *#Increased NC ratio.
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| *#*Atypical: ~ 1:2
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| *#*Not atypical: ~1:3.
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| *#Oval nuclei with small major axis to minor axis ratio.
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| *#*Atypical: major axis:minor axis = <=2:1.
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| *#*Not atypical: major axis:minor axis = >=3:1
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| *#**NB: round nuclei: major axis:minor axis = 1:1.
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| *#Small nucleoli (~1/5 the size of the nucleus).
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| ==Complex endometrial hyperplasia== | | ===Simple endometrial hyperplasia with atypia=== |
| | {{Main|Simple endometrial hyperplasia}} |
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| ===Microscopic=== | | ===Complex endometrial hyperplasia=== |
| Features:
| | *Abbreviated ''CEH''. |
| *Increase in size & number of glands + irregular shape - '''key feature'''. | | {{Main|Complex endometrial hyperplasia}} |
| *Cell stratification.
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| *Nuclear enlargement.
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| *Mitoses common.
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| *No nuclear atypia.
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| Notes:
| | ===Complex endometrial hyperplasia with atypia=== |
| *Normal "gland-to-stroma ratio" is 1:3.
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| *Two "touching" glands may be one gland in section.
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| DDx:
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| *[[Complex endometrial hyperplasia with atypia]].
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| *[[Endometrioid endometrial carcinoma]] - see ''[[endometrial carcinoma versus complex endometrial hyperplasia]]''.
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| Image:
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| *[http://www.webpathology.com/image.asp?n=1&Case=568 Endometrial hyperplasia (webpathology.com)].
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| ====Endometrial carcinoma versus complex endometrial hyperplasia====
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| Complex endometrial hyperplasia: | |
| *Non-confluent - glands distinct from one another.
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| =====Classic criteria for endometrial carcinoma=====
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| This is pimping material that shows up on exams.
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| Endometrial carcinoma has one of the following:<ref name=Ref_GP239>{{Ref GP|239}}</ref><ref name=pmid7074572>{{Cite journal | last1 = Kurman | first1 = RJ. | last2 = Norris | first2 = HJ. | title = Evaluation of criteria for distinguishing atypical endometrial hyperplasia from well-differentiated carcinoma. | journal = Cancer | volume = 49 | issue = 12 | pages = 2547-59 | month = Jun | year = 1982 | doi = | PMID = 7074572 }}</ref><ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Endometrium_11protocol.pdf http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Endometrium_11protocol.pdf]. Accessed on: 12 January 2012.</ref>
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| #Desmoplastic stromal response.
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| #Confluent cribriform growth. †
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| #Extensive papillary growth. †
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| #Severe cytologic atypia. †
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| Note:
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| * † There is a size cut-off for criteria 2, 3 and 4: > 2.1 mm.<ref name=pmid7074572/>
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| How to remember '''ABCDE''':
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| *'''A'''typia '''B'''ad.
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| *'''C'''onfluent cribriform growth.
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| *'''D'''esmoplasia.
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| *'''E'''xtensive papillary growth.
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| ==Complex endometrial hyperplasia with atypia==
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| *[[AKA]] ''complex atypical hyperplasia''. | | *[[AKA]] ''complex atypical hyperplasia''. |
| ===General===
| | {{Main|Complex endometrial hyperplasia}} |
| *High risk of transformation to [[endometrial carcinoma]].
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| ===Microscopic===
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| Features:
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| *Increase in size & number of glands + irregular shape - '''key feature'''.
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| *Cell stratification.
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| *Nuclear enlargement.
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| *Nuclear atypia:
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| **Round nuclei ~ 2-3x the size of a lymphocyte.
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| **Grey/translucent chromatin.
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| **Nucleoli.
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| *Mitoses common.
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| Note:
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| *Atypical nuclei often hide between non-typical nuclei, like peg cells in the [[fallopian tube]].
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| DDx:
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| *[[Complex endometrial hyperplasia]].
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| *[[Endometrioid endometrial carcinoma]] - see ''[[endometrial carcinoma versus complex endometrial hyperplasia]]''.
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| Image:
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| *[http://www.webpathology.com/image.asp?n=2&Case=568 Complex endometrial hyperplasia with atypia (webpathology.com)].
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| ===Sign out===
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| ====Insufficient confluence for carcinoma====
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| <pre>
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| ENDOMETRIUM, BIOPSY:
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| - COMPLEX ENDOMETRIAL HYPERPLASIA WITH ATYPIA, SEE COMMENT.
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| COMMENT:
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| The sections show architecturally complex crowded glands with focal
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| morular squamous metaplasia and focal cribriforming. Desmoplasia
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| is not identified. The degree of gland confluence is not considered
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| sufficient for the diagnosis of endometrial carcinoma. Nuclear atypia
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| is present focally.
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| </pre>
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| ====Insufficient extent for carcinoma====
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| <pre>
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| ENDOMETRIUM, BIOPSY:
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| - COMPLEX ENDOMETRIAL HYPERPLASIA WITH ATYPIA, SEE COMMENT.
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| COMMENT:
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| The sections show architecturally complex back-to-back glands with focal
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| morular squamous metaplasia and cribriforming. Desmoplasia is not present.
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| The extent, i.e. the size of the abnormality, is not considered sufficient
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| for the diagnosis of endometrial carcinoma.
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| </pre>
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| =Other= | | =Other= |